In this edition of Circulation: Arrhythmia andElectrophys-iology, Elayi and colleagues examined mortality in patients from the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study who received external (transthoracic) cardioversion shocks for atrial fibrillation (AF) compared with those who had not received cardioversion shocks. The AFFIRM trial studied 4060 patients with a history of AF and compared a strategy of rhythm control versus rate control. The strategy of using antiarrhythmic drug therapy to maintain sinus rhythm did not improve all-cause mortality when compared with rate control. In this substudy analysis of AFFIRM, the association of cardioversion shocks and subsequent risk of death was determined using Cox proportional hazards modeling. The primary finding was that patients who received cardioversion shocks were not at higher risk of death compared with the patients who did not receive cardioversion shocks. Other than an association of cardioversion with cardiac hospitalizations, these neutral findings were independent of ejection fraction, numbers of cardioversion episodes, or history of permanent versus paroxysmal AF.
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